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EW FEATURE 48 Secondary glaucoma challenges May 2015 Is it misdiagnosed? It is possible that secondary pigmen- tary glaucoma can be misdiagnosed as primary open angle glaucoma (POAG). "TIDs of the iris can be missed, especially if the patient is is helpful to gauge the severity of pigmentation. Dr. Masket said a misdiagnosis might occur if there is enough bleed- ing where the patient has a vitreous hemorrhage. "Patients may be referred to vitreoretinal specialists thinking there's a vascular occlusion or a retinal detachment only to discover that the problem has nothing to do with vitreoretinal pathology," he said. When patients initially have pigment dispersion with elevated pressure, they can also go on to develop microhyphemas, Dr. Masket said. Treatments available An IOL exchange is commonly what is needed for these patients. "The treatment is to remove the offend- ing aspect of the lens implant," Dr. Condon said. He thinks the most important thing is to be aware that there are a lot of patients who have these lenses, and if the cataract surgery was less than routine, there could potentially be a problem. Treat the elevated pressure and the inflammation that is associated with the iris chafing, D . Masket said. Patients may be put on topical corticosteroids and topical anti-glau- coma medications. Treatment is most often surgical management to exchange the of- fending lens for a different one with a more lubricous surface, he said. "Over time, we are able to wean patients from their drops, but it doesn't happen overnight," he said. This can take months to years. There are also temporary, non-sur- gical solutions, Dr. Masket said, like immobilizing the pupil. Dr. Jones said the best treat- ment is to alleviate the offending misplaced haptic by repositioning the lens. "If the pigmentary glauco- ma has gone on for some time, it is possible the trabecular meshwork is compromised and the optic nerve has suffered damage," he said. "The lens/haptic malposition should still be managed and the optic nerve pro- tected by glaucoma medication or surgery as the IOP, optic nerve exam, RNFL, and visual fields dictate." Is a glaucoma procedure necessary as well? If the patient does not have under- lying glaucoma and then had the inadvertent placement of the sin- gle-piece acrylic and developed secondary glaucoma, he or she should return to normal following removal of the offending element, Dr. Masket said. This occurs "al- most invariably," he said. But if the patient already had an underlying glaucoma problem, this will exacer- bate it. Remove the offending ele- ment, he said, and then reevaluate and manage. "After a certain period of time, [the surgeon] could do a glaucoma procedure if it's needed." Dr. Jones has not seen any cases where a glaucoma procedure is required, but he thinks they could exist. "MIGS is still relatively new to the armamentarium and is typically not used in pigmentary glaucoma," he said. But if the misplaced haptic is fixed and continued IOP ma - agement necessary, MIGS may be reasonable to consider. "Typically re- lieving the IOL haptic issue will help to normalize the IOP," he said. EW Editors' note: Drs. Masket and Condon have financial interests with Alcon. D . Jones has financial interests with A - bott Medical Optics (Abbott Park, Ill.). Contact information Condon: garrycondon@gmail.com Jones: jasonjonesmd@mac.com Masket: avcmasket@aol.com Handling continued from page 47 In the news Glaucoma visual field impr vement post-stem cell treatment Early results from the Stem Cell Ophthalmology Treatment Study (SCOTS) suggest bone marrow derived adult stem cells may be able to treat the optic nerve, according to Steven Levy, MD, president of MD Stem Cells (Ridgefield, Conn.). In 1 early case, the patient was a 64-year-old male with significant glaucoma damage and near total loss of peripheral vision. His central vision pretreatment was 20/70 OU. He received 3 separate injections for each eye of adult stem cells from his own bone marrow. On a follow-up exam 10 weeks following treatment, his peripheral vision had improved from a mean deviation of –31.30 dB pretreatment to –27.08 dB, about a 14% improvement. Study reports greater transient IOP rise in glaucomatous than non-glaucomatous cases during femto pretreatment Femtosecond pretreatment caused a greater transient rise in intraocular pressure (IOP) after treatment and a higher residual IOP after vacuum undocking in glaucomatous eyes than in non- glaucomatous eyes, according to Erica Darian-Smith and colleagues. In their nonrandomized, interventional, prospective case series, they compared results from 143 eyes (97 patients). Pretreatment was performed using a fluid-filled optical docking system (Liquid ptics Interface, Abbott Medical Optics, Abbott Park, Ill.). With the patient supine, the IOP was measured at 4 time points using a rebound tonometer (Icare Pro, Hartford, Conn.). Forty-three eyes (30.1%) had documented glaucoma. The mean baseline IOP was 20.2 mm Hg±4.2 in glaucomatous eyes and 18.9±4.0 mm Hg in non-glaucomatous eyes (P=.06). The mean change in IOP values between each timeframe and baseline was as follows: vacuum-on, 13.8±9.9 mm Hg and 11.1±6.9 mm Hg, respectively (P=.06); after treatment, 17.4±7.4 mm Hg and 14.1±7.2 mm Hg, respectively (P=.014); after undocking of vacuum, 9.9±5.4 mm Hg and 8.7±5.7 mm Hg, respectively (P=.24). The study authors cautioned that longer-term implications remain unknown. The study is published in the Journal of Cataract & Refractive Surgery. EW routinely seen only with dilation by the ophthalmologist and gonios- copy is not performed," Dr. Jones said. To avoid misdiagnosis, exam- ination of the angle is important and comparison to the opposite eye Are you a fan of EyeWorld? Like us on Facebook at facebook.com/EyeWorldMagazine Find us on social media EyeWorld@EWNews Keep up on the latest in ophthalmology! Follow EyeWorld on Twitter at twitter.com/EWNews